No proven benefit to common exam, group says, but Canadian association calls it 'integral'

The largest medical specialty group in the U.S. is recommending doctors stop routinely performing pelvic examinations in women.

The American College of Physicians (ACP) says that, for average-risk women who are not pregnant and who have no signs or symptoms of possible pelvic disease, the internal exams expose women to “unnecessary and avoidable harms” with no proven benefit. But the organization representing Canada’s gynecologists say the once-unquestioned procedure should remain an “integral” and fundamental part of women’s health care.

What is a pelvic examination?

The exam consists of visual inspection of the external genitalia, speculum examination of the vagina and cervix and “bimanual” examination of the uterus, ovaries and bladder. For the bimanual exam, a doctor inserts two fingers inside the vagina and places a hand on top of the abdomen, feeling for the position, shape and size of the uterus and ovaries. “Screening pelvic examination,” means speculum and bimanual exams in women with no pelvic symptoms.

The procedure has been taught to doctors for decades, said Dr. Molly Cooke, past president of the ACP (whose members are internal medicine doctors) and a member of the group’s clinical practice guidelines committee. “I graduated from medical school in 1977. And I was told this is part of the routine care of healthy women… It has been around for at least 40 years.”

Why is it done?

Pelvic exams are performed to detect cancer (other than cervical cancer), noncancerous masses, pelvic inflammatory disease or other benign gynecological conditions before symptoms develop. The new guideline does not apply to Pap smears for cervical cancer. Pap smears are of “incontrovertibly proven benefit,” Cooke said. But pelvic exams are frequently performed in women who aren’t due for a Pap smear. In the U.S., 62.8 million pelvic exams were performed in 2010 alone.

What did the authors do?

The new guideline is based on a systematic review of medical literature published from 1946 through to January 2014.

What did the authors find?

According to the new guideline, screening pelvic exams rarely detect important disease and don’t reduce mortality. The exams have a low level of accuracy for detecting ovarian cancer — the main condition that it was hoped could be detected earlier by routine bimanual exams.

“It’s reasonable to be concerned about ovarian cancer, because it’s a nasty cancer,” Cooke said. But several large studies have shown “it just doesn’t reliably detect ovarian cancer.”

The exams, meanwhile, can lead to false positive findings, unnecessary follow-up tests and procedures, as well as fear, anxiety, embarrassment, pain and discomfort. The new guideline appears in this week’s edition of Annals of Internal Medicine, ACP’s flagship journal.

What are others saying?

According to an accompanying editorial by two doctors at the University of California, San Francisco the pelvic examination “has become more of a ritual than an evidence-based practice.” But recommending doctors do away with something that has wide support “among women’s health providers will be met with a formidable challenge,” they add. At the very least they say that doctors who continue to offer it should be aware of the “uncertainty of benefit and the potential to cause harm through a positive test result and the cascade of events that follow.”

Dr. Jennifer Blake, professor of ob/gyn at the University of Toronto and Sunnybrook Health Sciences Centre in Toronto. (Handout Photo.)

“We still consider a bimanual examination an integral part of a pelvic examination,” said Dr. Jennifer Blake, CEO of the Ottawa-based organization. There are women for whom routine pelvic exams would be “clearly inappropriate,” she said, including women who have experienced sexual violence or trauma. For these women, “You would have to have very, very strong indications for doing it.”

Blake said the recommendation against pelvic exams in asymptomatic women is based on the “absence of evidence (of benefit) rather than any evidence. I think that can be very misleading to women.” She said the proper studies haven’t been done. A pelvic exam provides an opportunity to detect conditions a woman may be too embarrassed to mention to her doctor, Blake said, adding that surgery is never performed based on the findings from a pelvic exam alone.

The exam can detect ovarian cancers at earlier stages, she said, adding that the cost to the health system is “negligible. You’re not using any fancy equipment — you’re using your hands and you’re doing a physical assessment.” A bimanual examination should also not be painful, she added.

“I think that many women do find it’s a bit embarrassing and I suspect that men who are having a prostate exam or a rectal exam find that a bit embarrassing. Some women have been brought up to feel ashamed of their genitals and ashamed of their pelvis. Sometimes it’s a matter of helping them to feel better about themselves.”